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Hayes Barton UMC Student Ministries

2024-2025 Parental Consent Medical and Liability Release Form


  • Functions and Activities

I give my permission for my above named child to attend and participate in activities, programs, and trips sponsored by Hayes Barton UMC from June 2024 through September 2025 (unless otherwise noted in a separate permission form). Prior to my participation or the participation of my child, I acknowledge that there are certain risks associated with these activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents, illness or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware.

Release of Liability

By signing this parental consent and liability form, I expressly warrant that this child named above or I, if I am a participant, am capable of withstanding both the physical and mental demands of these activities. I also expressly assume all risks to the child or me participating in the activities, whether such risks are known or unknown to me at this time. I further release the church and its ministers, leaders, employees, volunteers and agents from any claim that my child may have or that I may have against them as a result of injury or illness incurred during the course of participation in these activities. This release of liability is also intended to cover all claims that members of the youth’s or my family or estate, heirs, representatives or assigns may have against the church or its ministers, leaders, employees, volunteers or agents from any and all claims arising from my participation or as a result of injury or illness of my child that occur while participating in the above described activities, programs, and trips from September 2023 through September 2024.

Permission to Use Photos, send E-mails or Text Messages

I give permission for the church, whether that being ministers, staff, leadership and/or volunteers to use photos of my child in church publications such as newsletters, church website, or other related areas (Facebook, YouTube, Twitter, Instagram). I also give permission for the church to contact me or my child via e-mails and/or text messages as a means of communication other than just telephone calls. I furthermore understand that the church will not use these means in an inappropriate way.

First Aid and Emergency Medical Treatment

I recognize that there may be occasions where the child named above, or I, if I am a participant, may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. I authorize an adult, in whose care the child has been entrusted, to consent to any X-ray, examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered by the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. In so doing, I agree to pay all fees and costs arising from this action to obtain medical treatment.

Youth Along with the leaders and other youth, I agree to conduct myself in a Christian manner. I promise to respect God, respect myself, respect other people, and respect property. I understand that my agreement holds me responsible to these things and the consequences thereof. I agree to participate in these activities of the church; my participation in church activities depends on my support of this agreement. By signing this covenant, I understand that I am subject to be sent home and am responsible for any legal consequences if I partake in any of the following activities: possession of illegal drugs, non-prescribed medication, alcohol or tobacco products, possession of weapons, disrespect of authority, or any other activity that adult leaders or pastors deem as inappropriate. I covenant to strive to make each activity/trip/retreat the best that it can be!

Date: January 28, 2025


First Participant Name

First Name*

Last Name*

Phone*
First Participant Date of Birth*
First Participant Information

School

Fall 2024 Grade

Youth's E-mail Address

Youth's Cell#

Medical History Include special medical needs or concerns such as asthma, allergies to medicines/foods/animals, health conditions, past surgeries, dietary needs, etc. that youth and children's workers should be aware of.

Medications Include ALL medicines that your child has permission to take at a regular youth group meeting or overnight retreats. All medicines must be in labeled containers and youth are not allowed to share with other youth.

Behavioral Health, Mental Health, and Additional Information Please list any behavioral health or mental health diagnoses AND/OR symptoms that your child has currently or has experienced in the past. Please also include ANY additional information that youth workers should know about your child.
First Participant Signature*
Second Participant Name

First Name*

Last Name*
Second Participant Date of Birth*
Second Participant Information

School

Fall 2024 Grade

Youth's E-mail Address

Youth's Cell#

Medical History Include special medical needs or concerns such as asthma, allergies to medicines/foods/animals, health conditions, past surgeries, dietary needs, etc. that youth and children's workers should be aware of.

Medications Include ALL medicines that your child has permission to take at a regular youth group meeting or overnight retreats. All medicines must be in labeled containers and youth are not allowed to share with other youth.

Behavioral Health, Mental Health, and Additional Information Please list any behavioral health or mental health diagnoses AND/OR symptoms that your child has currently or has experienced in the past. Please also include ANY additional information that youth workers should know about your child.
Second Participant Signature*
Third Participant Name

First Name*

Last Name*
Third Participant Date of Birth*
Third Participant Information

School

Fall 2024 Grade

Youth's E-mail Address

Youth's Cell#

Medical History Include special medical needs or concerns such as asthma, allergies to medicines/foods/animals, health conditions, past surgeries, dietary needs, etc. that youth and children's workers should be aware of.

Medications Include ALL medicines that your child has permission to take at a regular youth group meeting or overnight retreats. All medicines must be in labeled containers and youth are not allowed to share with other youth.

Behavioral Health, Mental Health, and Additional Information Please list any behavioral health or mental health diagnoses AND/OR symptoms that your child has currently or has experienced in the past. Please also include ANY additional information that youth workers should know about your child.
Third Participant Signature*
Fourth Participant Name

First Name*

Last Name*
Fourth Participant Date of Birth*
Fourth Participant Information

School

Fall 2024 Grade

Youth's E-mail Address

Youth's Cell#

Medical History Include special medical needs or concerns such as asthma, allergies to medicines/foods/animals, health conditions, past surgeries, dietary needs, etc. that youth and children's workers should be aware of.

Medications Include ALL medicines that your child has permission to take at a regular youth group meeting or overnight retreats. All medicines must be in labeled containers and youth are not allowed to share with other youth.

Behavioral Health, Mental Health, and Additional Information Please list any behavioral health or mental health diagnoses AND/OR symptoms that your child has currently or has experienced in the past. Please also include ANY additional information that youth workers should know about your child.
Fourth Participant Signature*
Fifth Participant Name

First Name*

Last Name*
Fifth Participant Date of Birth*
Fifth Participant Information

School

Fall 2024 Grade

Youth's E-mail Address

Youth's Cell#

Medical History Include special medical needs or concerns such as asthma, allergies to medicines/foods/animals, health conditions, past surgeries, dietary needs, etc. that youth and children's workers should be aware of.

Medications Include ALL medicines that your child has permission to take at a regular youth group meeting or overnight retreats. All medicines must be in labeled containers and youth are not allowed to share with other youth.

Behavioral Health, Mental Health, and Additional Information Please list any behavioral health or mental health diagnoses AND/OR symptoms that your child has currently or has experienced in the past. Please also include ANY additional information that youth workers should know about your child.
Fifth Participant Signature*
Sixth Participant Name

First Name*

Last Name*
Sixth Participant Date of Birth*
Sixth Participant Information

School

Fall 2024 Grade

Youth's E-mail Address

Youth's Cell#

Medical History Include special medical needs or concerns such as asthma, allergies to medicines/foods/animals, health conditions, past surgeries, dietary needs, etc. that youth and children's workers should be aware of.

Medications Include ALL medicines that your child has permission to take at a regular youth group meeting or overnight retreats. All medicines must be in labeled containers and youth are not allowed to share with other youth.

Behavioral Health, Mental Health, and Additional Information Please list any behavioral health or mental health diagnoses AND/OR symptoms that your child has currently or has experienced in the past. Please also include ANY additional information that youth workers should know about your child.
Sixth Participant Signature*
Seventh Participant Name

First Name*

Last Name*
Seventh Participant Date of Birth*
Seventh Participant Information

School

Fall 2024 Grade

Youth's E-mail Address

Youth's Cell#

Medical History Include special medical needs or concerns such as asthma, allergies to medicines/foods/animals, health conditions, past surgeries, dietary needs, etc. that youth and children's workers should be aware of.

Medications Include ALL medicines that your child has permission to take at a regular youth group meeting or overnight retreats. All medicines must be in labeled containers and youth are not allowed to share with other youth.

Behavioral Health, Mental Health, and Additional Information Please list any behavioral health or mental health diagnoses AND/OR symptoms that your child has currently or has experienced in the past. Please also include ANY additional information that youth workers should know about your child.
Seventh Participant Signature*
Eighth Participant Name

First Name*

Last Name*
Eighth Participant Date of Birth*
Eighth Participant Information

School

Fall 2024 Grade

Youth's E-mail Address

Youth's Cell#

Medical History Include special medical needs or concerns such as asthma, allergies to medicines/foods/animals, health conditions, past surgeries, dietary needs, etc. that youth and children's workers should be aware of.

Medications Include ALL medicines that your child has permission to take at a regular youth group meeting or overnight retreats. All medicines must be in labeled containers and youth are not allowed to share with other youth.

Behavioral Health, Mental Health, and Additional Information Please list any behavioral health or mental health diagnoses AND/OR symptoms that your child has currently or has experienced in the past. Please also include ANY additional information that youth workers should know about your child.
Eighth Participant Signature*
Ninth Participant Name

First Name*

Last Name*
Ninth Participant Date of Birth*
Ninth Participant Information

School

Fall 2024 Grade

Youth's E-mail Address

Youth's Cell#

Medical History Include special medical needs or concerns such as asthma, allergies to medicines/foods/animals, health conditions, past surgeries, dietary needs, etc. that youth and children's workers should be aware of.

Medications Include ALL medicines that your child has permission to take at a regular youth group meeting or overnight retreats. All medicines must be in labeled containers and youth are not allowed to share with other youth.

Behavioral Health, Mental Health, and Additional Information Please list any behavioral health or mental health diagnoses AND/OR symptoms that your child has currently or has experienced in the past. Please also include ANY additional information that youth workers should know about your child.
Ninth Participant Signature*
Tenth Participant Name

First Name*

Last Name*
Tenth Participant Date of Birth*
Tenth Participant Information

School

Fall 2024 Grade

Youth's E-mail Address

Youth's Cell#

Medical History Include special medical needs or concerns such as asthma, allergies to medicines/foods/animals, health conditions, past surgeries, dietary needs, etc. that youth and children's workers should be aware of.

Medications Include ALL medicines that your child has permission to take at a regular youth group meeting or overnight retreats. All medicines must be in labeled containers and youth are not allowed to share with other youth.

Behavioral Health, Mental Health, and Additional Information Please list any behavioral health or mental health diagnoses AND/OR symptoms that your child has currently or has experienced in the past. Please also include ANY additional information that youth workers should know about your child.
Tenth Participant Signature*
Participant Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Please attach a copy of your insurance card
  
Insurance Card
Valid file types: JPG, GIF, PNG, and PDF
Guardian Contact Information

Parent/Guardian Names

Guardian Work#

Guardian #2 Work#

Guardian Cell#

Guardian #2 Cell#

Guardian's E-mail Address

Guardian #2 E-mail Address

Primary Medical Doctor Name (if applicable)
If Participant is a Minor I represent that I am the parent/guardian of the child listed, who is under 18 years of age. I have read this Consent & Waiver Form and am fully familiar with the contents thereof. I give permission for the child named to participate in the activities of this church. I hereby consent to the Permission and Waiver Form, including the Release of Liability, on behalf of my child, and agree that this Permission and Waiver Form shall be binding upon me and my estate. I realize that if my child breaks the covenant, he/she is subject to be sent home at my expense.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

School

Fall 2024 Grade

Youth's E-mail Address

Youth's Cell#

Medical History Include special medical needs or concerns such as asthma, allergies to medicines/foods/animals, health conditions, past surgeries, dietary needs, etc. that youth and children's workers should be aware of.

Medications Include ALL medicines that your child has permission to take at a regular youth group meeting or overnight retreats. All medicines must be in labeled containers and youth are not allowed to share with other youth.

Behavioral Health, Mental Health, and Additional Information Please list any behavioral health or mental health diagnoses AND/OR symptoms that your child has currently or has experienced in the past. Please also include ANY additional information that youth workers should know about your child.
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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